An 18-year-old woman who recently immigrated to the United States comes to the office for a pre-employment physical. She is looking forward to starting a job as a nursing aide and also plans to enroll in night classes to become a registered nurse. The patient is engaged to be married and is planning on returning to her country to visit her family next month and to undergo a "female circumcision." She says that this matter is very important because it is considered a rite of passage in her culture. Her family feels strongly that she should undergo the procedure in preparation for marriage. Two of the patient's older sisters have already undergone the procedure. Her medical history is unremarkable and physical examination reveals no abnormalities. Which of the following is the most appropriate response?

Question

An 18-year-old woman who recently immigrated to the United States comes to the office for a pre-employment physical.  She is looking forward to starting a job as a nursing aide and also plans to enroll in night classes to become a registered nurse.  The patient is engaged to be married and is planning on returning to her country to visit her family next month and to undergo a "female circumcision."  She says that this matter is very important because it is considered a rite of passage in her culture.  Her family feels strongly that she should undergo the procedure in preparation for marriage.  Two of the patient's older sisters have already undergone the procedure.  Her medical history is unremarkable and physical examination reveals no abnormalities.  Which of the following is the most appropriate response?

Quizplus · Accepted Answer

Explanation: Female genital cutting, also known as female circumcision or genital mutilation, is a cultural practice, predominantly performed in some parts of Africa. It involves manipulation or removal of external genital organs and is considered an important rite of passage into womanhood in some cultures. Most, but not all, of the procedures are performed by nonmedical practitioners. Anesthesia and antibiotics are rarely administered, and hemorrhage and infection can result. Potential long-term gynecological complications include genital pain, scarring, infection, infertility, and difficulty with coitus and/or vaginal delivery. In this situation, the physician's response must be culturally sensitive and nonjudgmental. Many women who undergo female genital cutting do not consider it mutilation. A sensitive approach includes asking the patient if she has any concerns about the procedure, avoiding referring to the procedure as genital mutilation, and educating her about the medical risks. (Choices A and C) These statements are likely to be perceived as judgmental, unsupportive, and alarming. In addition, the term "genital mutilation" is insensitive and may be experienced as critical. Patients benefit most when the physician is sensitive to their culture and explains risks and benefits in a nonjudgmental manner. (Choice B) In some cultures it is common for medical decisions to include family members. This patient may or may not feel pressured by her family, and this question may be experienced as culturally insensitive. If the physician is concerned that the patient is being pressured, then an open-ended approach is preferred, such as asking, "How are you feeling about having the procedure?" (Choice D) Although the procedure should be performed under sterile conditions and with anesthesia, it would be inappropriate to suggest that this can be done only in the United States. Educational objective: Women interested in undergoing female circumcision should be approached in a culturally sensitive and nonjudgmental manner. They should be advised of the health risks associated with the procedure, especially if performed by a nonmedically trained practitioner. References: Female genital mutilation/cutting in Africa. (http://www.ncbi.nlm.nih.gov/pubmed/28540220) Effect of female genital mutilation/cutting on sexual functions. (http://www.ncbi.nlm.nih.gov/pubmed/27938869)

An 18-Year-Old Woman Who Recently Immigrated to the United States